Healthcare Provider Details

I. General information

NPI: 1669754057
Provider Name (Legal Business Name): KEVIN SADATI, DO PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NEWPORT CENTER DR SUITE 100
NEWPORT BEACH CA
92660-7601
US

IV. Provider business mailing address

27462 PASEO BOVEDA
SAN JUAN CAPISTRANO CA
92675-1890
US

V. Phone/Fax

Practice location:
  • Phone: 949-706-7776
  • Fax:
Mailing address:
  • Phone: 760-947-5177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number20A9343
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number20A9343
License Number StateCA

VIII. Authorized Official

Name: DR. KEVIN S SADATI
Title or Position: PRESIDENT
Credential: DO
Phone: 760-946-5177